Pacesetters Covid-19 Symptom Sheet

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Please fill out the following form with a parent/guardian the same day of a meet. For Practice: on Tuesday through June and Monday and Wednesday thereafter. If you have answered yes to any questions or your temperature is 100.0 or above, you must stay at home. The athlete must be fever free for 24 hours without medication prior to returning.

Email *

YYYY

Athlete Last Name *

Athlete First Name *

COVID Self screening Please conduct a COVID self-screening the morning of the event. If you answer “YES” to any question, please refrain from attending the event. Temperature screenings will be in place. Do you have a cough, congestion or runny nose that is not tied to an existing health condition (e.g., allergies, etc.)? Are you having trouble breathing that is not tied to an existing health condition (e.g., asthma, COPD, etc.)? Do you have a new loss of taste or smell? Are you experiencing extreme fatigue, muscle or body aches not associated with an existing condition? *

Have you been within 6ft, without a mask, for 15 minutes with someone who is positive for Covid-19? (This would be an exposure) *

Yes

Have you traveled to a "hot spot" since your last survey? if you answered yes, please monitor yourself for symptoms. You may want to get tested. The 14 day quarantine is not mandatory. You may resume normal activity. *

Yes

Parent/Guardian: I authorize, that my athlete has been given permission to participate in Pacesetters sponsored athletic practice/meets. I assume all risk associated with return to sports. I have answered all questions above honestly. If I have questions, I will contact club administration. Type name and date below. *

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